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Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication

Austin, Naola MD*; Goldhaber-Fiebert, Sara MD*; Daniels, Kay MD; Arafeh, Julie MSN, RN; Grenon, Veronique FCAS, MAAA§; Welle, Dana DO, JD§; Lipman, Steven MD*

doi: 10.1213/ANE.0000000000001601
Obstetric Anesthesiology
Free
SDC

As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors’ local experience with obstetric simulation drills and optimization of team communication.

From the *Departments of Anesthesiology, Perioperative and Pain Medicine and Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California; Center for Advanced Pediatric and Perinatal Education, Stanford Medicine, Stanford, California; and §the Risk Authority, Stanford, California.

Accepted for publication August 12, 2016.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Naola Austin, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, H3580 MC 5640, Stanford, CA 94305. Address e-mail to naola@stanford.edu.

Because severe maternal morbidity in the United States has steadily increased,1,2 the California Maternal Quality Care Collaborative Pregnancy Associated Mortality Review3 and United Kingdom Confidential Enquiry4 have suggested opportunities to minimize the preventable harm. To capitalize on these opportunities, and to tailor safety solutions to each labor and delivery unit, it is important to first create a robust culture of safety. This includes a just culture in which iatrogenic harm is appropriately identified and investigated to define the contribution of systems factors that may have contributed to the risk of individual error.5,6 A nonpunitive environment must be created to encourage reporting and investigation of adverse events and systems, and to effectively translate institutional lessons into systems innovations that will reduce the risk of future patient harm.7

Having pioneered the field of patient safety,8,9 anesthesiologists have expertise in critical care, resuscitation, culture of safety, safety systems, operational efficiency, and crew/crisis resource management.10 Along with daily experience on the labor and delivery unit, these skills uniquely position anesthesiologists to both recognize opportunities for improvement and to help lead interprofessional teams to identify and implement systems solutions that will enhance maternal and perinatal patient safety.

Caring for multiple patients with dynamic acuity results in unpredictable and overlapping analgesic and anesthetic care. The stages of birth can span multiple shifts of multidisciplinary care providers, necessitating handovers that may increase the potential for patient harm.11 Similar to high-reliability organizations such as nuclear power and aviation, relatively infrequent but sudden and potentially disastrous emergency conditions require a highly coordinated team response.12,13 Well-intentioned regulatory requirements for patient privacy, drug and equipment safety, outcome measurement, and patient satisfaction are making obstetric care and systems improvements more complex, not less.

Building comprehensive strategies to maximize obstetric safety is imperative because health systems are under pressure to simultaneously support low intervention birth,14,15 provide fail-safe responses during emergencies,16 and provide efficient care.17 Societal and patient expectations of perfect outcomes increase the risk of legal liability18 and second victim psychological trauma.19

Considerable effort in recent years has been devoted to obstetric safety strategies in the form of cognitive aids, toolkits, and bundles. Examples include the Society for Obstetric Anesthesia and Perinatology preoperative huddle,20 toolkits by the California Maternal Quality Care Collaborative,21 and bundles by the National Partnership for Maternal Safety.15 These tools contain recommendations for system-level solutions (eg, structured communication and simulation), but their scope is relatively focused and does not address the practical challenges involved in the translation of individual safety strategies into a unit-wide culture of safety to protect both mothers and babies.

Most obstetric safety programs were primarily initiated by obstetricians and nurses; the perspectives of anesthesia providers are often not reflected in these programs.22–30 For example, obstetricians at Yale-New Haven Hospital developed the University Hospital Obstetric Safety Program and reported improvements in safety and liability claims with the implementation of a patient safety nurse, protocol-driven care, crew resource management training, a patient safety committee, 24-hour obstetric coverage, and an anonymous event reporting system.22–24

Using a multidisciplinary group of authors that includes the patient safety expertise of obstetric anesthesiologists, this article aims to build upon previously published work reviewing simulation31,32 and team communication33 as obstetric patient safety tools. Recognizing some areas of overlap with the TeamSTEPPS curriculum,34 which uses teamwork and communication to improve patient safety, we describe examples from local experience at Lucile Packard Children’s Hospital Stanford. Operational details from local approaches may help bridge the gap between individual safety strategies and an institutional culture of safety. Although there is no one-size-fits-all strategy for every labor and delivery unit, a comprehensive approach provides the opportunity to minimize preventable harm through customization for individual units.

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OBSTETRIC SIMULATION DRILLS

Available Evidence

The American College of Obstetricians and Gynecologists (ACOG) recommends multidisciplinary team obstetric crisis drills as a means to refine communication skills as well as to discover and correct latent systems issues.18 Simulation experts invoke adult learning theory to support the conduct of drills: “Adults learn best when they are actively engaged in the process, participate, play a role, and experience not only concrete events in a cognitive fashion, but also transactional events in an emotional fashion.”35

Simulation can recreate realistic health care settings and provide an environment to teach, learn, practice, and assess teamwork skills.36,37 Although teamwork is difficult to measure,38,39 in situ drills and other multidisciplinary teamwork exercises may lead to improved team performance during obstetric emergencies.40,41 Maslovitz et al42 used simulation to identify recurrent deficiencies in care, including inadequate cardiopulmonary resuscitation, delayed transfer to the operating room, delayed transfusion, and incomplete documentation.

Optimal team performance during stressful situations is challenging. In a study at our institution of simulated maternal cardiac arrest, experienced multidisciplinary teams performed proper chest compressions only 56% of the time and frequently omitted critical elements of maternal resuscitation.43 Other studies on first responder performance mirror these challenges.44–46

Team performance and patient safety are enhanced when teams are organized and efficient.47 To maximize effectiveness, experts have advocated going beyond the shared mental model paradigm of everyone being on the same page to everyone on the team understanding their role and the roles of others.48 Role clarity is crucial for optimal and efficient team performance during a crisis.10 In one study, simulated survival increased from 0% to 89% after the curriculum focused on organizational aspects of team performance.49

Crisis roles are a well-established means of improving teamwork, communication, and efficiency during an emergency. Roles can be developed based on critical tasks (eg, airway management, delivery of fetus, and recording events) and/or geographic location of the tasks (eg, head of the bed, near the uterus, or near the leader).50–54 Practicing roles during simulation drills and evaluating their effectiveness during video debriefing can emphasize their importance.54–57

In addition to improving team performance and role clarity, in situ simulation can probe for systems issues in existing units, new services, or new facilities.7,58–61 Implementing systems changes will vary by institution, but Pettker et al23 reported successful use of a patient safety committee. In addition to systems probing, drills can be used as a dress rehearsal to practice care coordination before a complex case (eg, ex-utero intrapartum treatment procedure or conjoined twin delivery).62

Review articles by Pratt31 and Merién et al32 suggest potential uses of simulation on labor and delivery units including teaching, evaluation, safety assessment, and teamwork building. Templates such as TEACH Sim may assist with the challenges of health care simulation implementation.63 Levine’s comprehensive textbook explores the history and practical aspects of simulation in health care and highlights the importance of debriefing to solidify learning.64

The literature supports the use of both facilitated debriefing led by an instructor and participant-led debriefing.65,66 Experienced debrief facilitators encourage reflection and evaluation of strengths and weaknesses in clinical performance.67 The appropriate use of video allows participants to observe the complexities of high-intensity care and to avoid retrospective bias.68 There is limited evidence for the efficacy of video playback compared with oral debriefing alone; however, reviewing specific video segments can facilitate the discussion of learning objectives and challenging moments.69–71 Concise team-led debriefings after simulation reinforce open lines of communication that can be extended to actual clinical events and strengthen an institutional culture of safety.72

Evidence regarding the effectiveness of simulation-based learning on the labor and delivery unit is inconclusive. Crofts et al73 measured improvements in management that persisted for up to 1 year in simulations of shoulder dystocia. However, a multicenter, randomized controlled trial by the same group did not find a benefit of simulation or teamwork training compared with a traditional curriculum.74 Daniels et al75 used simulation of amniotic fluid embolism to identify knowledge gaps and improve communication, but they did not perform longitudinal follow-up. Thompson et al76 used in situ simulation to identify and correct deficiencies in eclampsia care for simulated patients, but they did not evaluate outcomes for actual patients. Kim et al77 found an increase in recognition of shoulder dystocia accompanied by a paradoxical increase in adverse real patient outcomes after a simulation-based training curriculum. Clinical relevance is difficult to extrapolate given the heterogeneity of simulation curricula and study designs, combined with the inherent challenges of outcomes research.

Simulation-based learning has advantages;78 however, 2 important limitations are worth noting. A systematic review of simulation for patient safety training hypothesized that simulation could “place demand on valuable resources that could be applied elsewhere in patient safety efforts,”79 but it found no data indicating potential or actual harm. Also, simulation-based learning cannot be a one and done exercise. A screen-based simulation study by Schwid and O’Donnell80 found significant decline in skills at 6 months and again at 2 years after Advanced Cardiac Life Support training. More research is needed to evaluate the value and necessary dose81,82 of simulation-based training for improved clinical outcomes for actual patients. With that said, “no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it.”83

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Multidisciplinary Author Experience

Our high-acuity labor and delivery unit has approximately 4500 annual deliveries and is staffed by nearly 100 nurses, 60 attending obstetricians, 23 attending anesthesiologists, fellows, and residents. Our in situ, multidisciplinary Obstetric Simulation (OBSIM) program has been a cornerstone of our efforts to create a culture of safety on the labor and delivery unit. OBSIM started as a small pilot program and incrementally grew thanks to positive participant feedback and safety improvements. More than a decade later, >200 simulations have been performed. Implementation of OBSIM and other safety strategies at our high-acuity center were temporally associated with a significant decrease in obstetric-related legal claims (Figure 1).

Figure 1.

Figure 1.

Simulation on the labor and delivery unit can be implemented in many ways with iterative steps (Table 1, Figure 2). Our process starts with an OBSIM faculty team consisting of anesthesiologists, obstetricians, nurses, and simulation professionals. At our institution, we have collaborated with the Office of Emergency Management, Family Centered Care Program, and Office of Risk Management.

Table 1.

Table 1.

Figure 2.

Figure 2.

Simulation topics are selected from challenging real cases, risk management data from our institution, and national reports of high-risk conditions for maternal or fetal morbidity, mortality, or litigation. Scenarios have included postpartum hemorrhage, emergency cesarean delivery, maternal cardiac arrest, and several other emergency situations (Supplemental Digital Content, Supplemental Table 1,.

Each scenario is designed with a specific clinical question that leads to team and specialty-specific learning objectives and metrics (Table 2). Planning the scenario and simulation schedule involves approximately 6 hours of multidisciplinary meetings, email correspondence, and 2 to 3 hours of dress rehearsal. Approximately 15 sessions per scenario accommodate all nurses (3–4 per session), technicians (1–2 per session), and rotating obstetric and anesthesiology residents and fellows (2–6 per session). Attending obstetrician and anesthesiologist participation is voluntary, but it is increasing. If participant surveys and/or OBSIM faculty consensus suggest that continued education is warranted, scenarios are revised and repeated.

Table 2.

Table 2.

One of the biggest challenges of in situ simulation is securing an empty room in an unpredictably busy labor and delivery unit. To minimize the cancellation of a scheduled simulation session, we create backup plans such as converting a labor room or conference room into a mock operating room.

Scheduling time for participants and faculty to focus on simulation is challenging. Many physicians on the OBSIM faculty initially volunteered time because of their interest in quality improvement. With increasing success of the program, salary support was obtained from the hospital and grants were obtained from the risk management department. Nurse OBSIM faculty compensation is built into salaried job descriptions. Nurse participant time is funded through educational budgets and hospital initiatives. Required resident and fellow participation is protected educational time aimed at meeting Accreditation Council for Graduate Medical Education (ACGME) milestones. We are utilizing honorarium compensation to incentivize attending physician participation, but medical malpractice discounts and institutional credentialing requirements have also been considered.

Simulation sessions begin with introductions and the explanation that simulation is a challenging but safe zone for learning in which performances, positive or negative, must be kept confidential. Errors are framed as opportunities for adult learning, professional growth, building teamwork, and improving systems for patient care. Faculty, participants, and observers must sign confidentiality forms, but they can opt in or out of signed audio-visual consent for video use after the session.

Teams can be naïve to the scenario, privy to the scenario, encouraged to use cognitive aids, or allowed to repeat the scenario. Relevant task training and/or brief didactics are incorporated before or after the scenario to reinforce knowledge, technical skills, or interpersonal skills. In each simulation drill, we maintain specialty fidelity (ie, obstetricians function as obstetricians) and encourage native practices with acknowledgment that simulation is not real life, and reactions to a mannequin or standardized patient may be different than for a real patient.

After the 20- to 30-minute simulated scenario, we encourage a 5-minute team debrief to identify systems or human factors that positively or negatively affected patient care. Practicing 5-minute team debriefs after simulated scenarios may encourage providers to conduct them for quality improvement and teamwork building after actual patient care events. The 5-minute team debrief is followed by a 30- to 45-minute facilitated debrief session in a private room.

The first 5 minutes of the facilitated debrief session are dedicated to empowering staff to report and correct systems issues. Issues with relatively simple solutions are sent directly to management personnel. Complex systems issues utilize our Obstetric Safety Committee, which discusses and implements solutions from multiple perspectives. Our Obstetric Safety Committee meets monthly and consists of nurses from the labor and delivery, antepartum, postpartum, and neonatal intensive care units, physicians in obstetrics, anesthesiology, neonatology, and maternal fetal medicine, as well as pharmacists, nursing leaders, and risk management representatives. All labor and delivery unit providers are welcome, and they are encouraged to bring up any safety concerns at any time to any member of the Obstetric Safety Committee.

Examples of systems level improvements at our institution include moving the code cart from a locked closet to a more easily accessible location, streamlining the process for massive transfusion protocol activation, addition of more self-inflating bag valve masks throughout the unit, creation of a postpartum hemorrhage medication kit, and purchase of standing stools that do not slide during the performance of chest compressions. A large in situ simulation program such as ours requires significant resources, but a smaller program may still improve the teamwork and uncover the important systems issues and patient safety improvement opportunities. We welcome visitors interested in learning more about OBSIM and sharing their experience with us.

Anesthesiologists are actively involved as OBSIM faculty and participants. As faculty, anesthesiologists advocate for simulation topics that educate anesthesiology residents, fellows, and attending physicians as leaders during obstetric crisis situations. OBSIM is a way for anesthesiologists to add their expertise, unique perspective, and patient care priorities to the important patient safety initiatives and systems improvements on our labor and delivery unit. Having seats at the table for OBSIM and Obstetric Safety Committee cultivates collegial working relationships and a mutual respect for the contributions of each specialty to the labor and delivery unit care team.

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COMMUNICATION

Available Evidence

Effective communication among providers and with patients is critical on the labor and delivery unit. Open lines of communication with patients and families can elicit critical safety information.84 The Sentinel Event Alert on Preventing Infant Death and Injury During Delivery of the Joint Commission found that “communication issues topped the list of identified root causes (72%), with more than one-half of the organizations (55%) citing organization culture as a barrier to effective communication and teamwork.”85 Closed claim review of malpractice cases in obstetrics and gynecology identified communication as a contributing factor in 31% of adverse events.86 Communication barriers included hierarchy and intimidation, failure to function as a team, and failure to follow the chain of communication. In anesthesia closed-claims analysis, poor communication between the obstetrician and the anesthesiologist was identified as a potentially preventable cause of newborn injury.87

Similar to any technical skill, communication must be practiced and requires systems to support reliability. Techniques for clear and concise communication have been published extensively,51,88–90 and practicing communication during routine care may improve effectiveness during emergencies.10 Some well-recognized communication techniques are summarized in the Supplemental Digital Content (Supplemental Table 2, http://links.lww.com/AA/B519).

Multidisciplinary rounds that include nurses, physicians, and other providers may improve outcomes,91 reduce adverse events,92,93 reduce costs,94,95 and improve staff satisfaction.96 The quality of multidisciplinary rounding is improved with standardization, including time, place, and goals of rounding.97 Multidisciplinary team rounding promotes open discussion, even in the setting of competing priorities among different members.98

Work-hour restrictions and varying shift and rotation schedules create concerns surrounding patient handoffs11,99 that may be mitigated with improved communication.100,101 Mobile phones and other technology may improve communication,102,103 but they must protect patient privacy and have acceptable latency for delivery of critical messages.104

Whiteboards or electronic displays can provide perspective on the labor and delivery unit–wide census, acuity, and staffing, or of an individual patient’s clinical situation, goals, and care team. Despite widespread use, clear evidence of safety or communication benefits conferred by displays is limited.26,105–108

Communication is essential to report clinical deterioration and to appropriately escalate care early in a crisis. When a crisis is identified and announced, a well-communicating team assembles, obtains relevant history, diagnoses likely etiologies, assigns roles, provides essential care, anticipates and plans for potential needs or outcomes, reassesses, adapts treatment as necessary, and debriefs together afterward for quality improvement.18 Activation of rapid response teams has been associated with the decreased incidence of cardiac arrest, decreased intensive care unit admissions, and improvements in the survival of inpatients.109 Promising work has been done on maternal early warning systems to identify vital signs or other parameters that may signal an impending obstetric crisis.110,111 Providers on the front line should be encouraged to trust their clinical judgment and to report when something just does not seem right without the fear of embarrassment.112,113

Communication and disclosure after a crisis help to maintain the relationship of trust between providers and patients. Early acknowledgment of an adverse event may decrease the risk of litigation.114 Even though the Joint Commission requires disclosure of adverse events for hospital accreditation, studies have found that lack of training, cultural bias to not admit error, concerns about increased legal liability, and mixed messages from leadership inhibit physician involvement in disclosure.115,116 The medicolegal aspects of saying I’m sorry are critical because protective apology laws prohibiting use of these statements as legal evidence differ from state to state.117

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Multidisciplinary Author Expermience

In addition to simulation, our institution uses many strategies for improved communication among providers and with patients. Select strategies described here include multidisciplinary rounds, using technology efficiently, patient lists to accompany verbal handoffs, patient displays, high-risk obstetric anesthesia planning, obstetric-specific emergency announcements, and maintaining open lines of communication with patients, including disclosure when appropriate.

Obstetricians, anesthesiologists, and charge nurses from the labor and delivery, antepartum, postpartum, and the neonatal intensive care units attend morning and evening multidisciplinary rounds in a private hallway on the labor and delivery unit. Succinct discussion (ie, obstetric history, anesthesia concerns, major fetal and maternal comorbidities, and care plan) of approximately 30 labor, operative, antepartum, and obstetric patients on other units requires approximately 10 to 15 minutes.

To facilitate efficient communication, our labor and delivery unit has purchased dedicated mobile phones by role (eg, anesthesiology attending, obstetric attending, obstetric chief resident, anesthesiology resident, charge nurse, or scrub technician). The anesthesiology attending physician coming on shift gets the anesthesia attending phone from the outgoing attending and can always be called with that same number. For ease of use, the phones are programmed with numbers for other providers in the contacts. For backup in the event of mobile phone failure, we use a paging operator, an online paging system, a paging application, and a display board with the names and alternate contact numbers for staff on duty.

Providers may use their personal electronic devices to receive pages and access the electronic medical record after the devices are password protected and encrypted by the Stanford information technology department. These security measures protect health information in the event of a lost device and provide convenience such as not carrying a physical pager and being able to access electronic medical records from home.

A patient list is automatically generated from the electronic medical record to facilitate verbal handoffs. It serves as a cognitive aid of pertinent patient details that could be difficult to remember on a busy unit or in the stress of an emergency. Secure disposal bins are available throughout the unit to make it easy for providers to dispose of the printed material and to ensure that patient privacy is always protected.

Through an Agency for Healthcare Research and Quality grant, providers at our institution are studying optimal maternal and fetal electronic displays, but current practice relies on whiteboards. The front desk board has room number, patient initials, date and time of admission, nurse and obstetrician name, and critical obstetric and anesthesia details. Limited space does not allow a large provider workroom, and the placement of the board in a relatively public place creates a conflict between communication and patient privacy. Institutional policy ensures that the information displayed remains compliant with regulations such as the Health Insurance Portability and Accountability Act.

Whiteboards in each labor and operating room display patient-centered and provider-centered information (ie, nurse name, baby name and gender, gestational age, cervical exam results, membrane rupture and meconium status, hematocrit, and platelet count). Patient preference for certain information to be added or deleted on the whiteboard is honored.

Patients with anesthesia risk factors require earlier planning and communication whenever possible. Obstetricians are encouraged to refer patients with specific conditions (Table 3), for a 30- to 60-minute antepartum consultation at our weekly high-risk obstetric anesthesia clinic. Anesthesia concerns, options, and plans are discussed among the obstetric anesthesia faculty and with the referring obstetrician and patient. Complex cardiac patients are discussed at a monthly conference attended by maternal-fetal medicine, congenital cardiology, and cardiac and obstetric anesthesiology physicians. Delivery coordination (Table 4) is documented in the electronic medical record to improve communication, safety, and efficiency.

Table 3.

Table 3.

Table 4.

Table 4.

Our hospital operator communicates obstetric emergencies (OBSTAT) using overhead announcements and text pages. An OBSTAT assembles obstetricians, anesthesiologists, nurses, and technicians. In the event of cardiac or respiratory arrest, our obstetric code blue mobilizes everyone from the OBSTAT team, plus an adult code blue team, neonatologists, pharmacists, and resources for potential perimortem cesarean delivery. The observation that anesthesiologists and obstetricians had more defined roles than nurses during simulated maternal cardiac arrests led to the development of nursing crisis roles (Table 5). Communication to assign and perform these roles is taught in our Obstetric Life Support (OBLS) curriculum and practiced during OBSIM. The preassigned roles represent a major change in practice for nursing staff and continue to evolve on the basis of staff feedback.

Table 5.

Table 5.

Communication with patients and families on the labor and delivery unit is challenging, especially during and after emergencies. Providers at our institution have expressed satisfaction with our disclosure and difficult conversations curriculum created in collaboration with the risk management group. The curriculum outlines the importance of: (1) being empathetic and saying I’m sorry without blame, (2) being objective and avoiding speculation during conversations and documentation, (3) using provider resources including risk management and peer support, and (4) maintaining open lines of communication among providers and with patients.

Communication to and from anesthesiologists is critical for maximizing safety on the labor and delivery unit. Anesthesiologists can add their unique perspective and skill set by actively participating during multidisciplinary rounds, daily workflow, complex patient planning, obstetric emergencies, and communication with patients and families.

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CONCLUSIONS

Obstetric patients expect and deserve maximal safety, regardless of production pressure and ever-increasing regulatory requirements. With a legacy of patient safety efforts, anesthesiologists are uniquely suited to help foster a culture of safety on the labor and delivery unit. With a multidisciplinary author perspective that includes anesthesiologists, this article summarized the available evidence and local experience of conducting simulation drills and optimizing communication to improve obstetric safety.

Labor and delivery units are heterogeneous, and even the most comprehensive safety strategies may not be applicable or practical for every unit. Therefore, these broad strategies and operational details must be adapted for the individual needs and resources of each unit.

Simulation and communication interventions are difficult to objectively research in the complex environment of the labor and delivery unit. In addition, parallel safety initiatives make it difficult to determine causation between patient safety efforts and outcomes. We are not perfect, but our labor and delivery unit has seen improvements in provider satisfaction, legal liability, and local culture of safety that coincide with implementation of multidisciplinary in situ simulation and communication strategies. Ideally, other labor and delivery units will find our experience useful and continue to build more comprehensive and measurable strategies for obstetric safety.

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DISCLOSURE

Name: Naola Austin, MD.

Contribution: This author helped analyze the data and write and revise the manuscript.

Name: Sara Goldhaber-Fiebert, MD.

Contribution: This author helped write a section of the manuscript.

Name: Kay Daniels, MD.

Contribution: This author helped write a section of the manuscript.

Name: Julie Arafeh, MSN RN.

Contribution: This author helped write a section of the manuscript.

Name: Veronique Grenon, FCAS, MAAA.

Contribution: This author helped analyze the data and write a section of the manuscript.

Name: Dana Welle, DO, JD.

Contribution: This author helped analyze the data and write a section of the manuscript.

Name: Steven Lipman, MD.

Contribution: This author helped analyze the data and write and revise the manuscript.

This manuscript was handled by: Cynthia A. Wong, MD.

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